Literature Reivew

Mental Health Help-Seeking Experiences of Hispanic Women in the United States: Results from a Qualitative Interpretive Meta-Synthesis Brittany H. Eghaneyan and Erin Roark Murphy

School of Social Work, University of Texas, Arlington, USA

ABSTRACT The purpose of this study was to conduct a qualitative interpretive meta- synthesis to examine the experiences and perceptions of mental health help-seeking behaviors by Hispanic women in the United States. Synthesis of five studies resulted in one major theme of determinants of mental health help-seeking organized into three subthemes: (1) societal determi- nants, (2) health services system, and (3) individual determinants. These results provide a more holistic understanding of the mental health help- seeking experiences of Hispanic women, an important consideration when developing interventions to address the disparities in access to and quality of mental health treatment experienced by this unique population.

KEYWORDS Help-seeking; qualitative interpretive meta-synthesis; Hispanics; mental health; health disparities

Introduction

Hispanics are the largest minority group in the United States, accounting for 17% of the current population and projected to make up more than a quarter (28%) of the population in 2060 (Colby & Ortman, 2015). This growing population’s lifetime prevalence rate of psychiatric disorders is 28% for men, and even higher for women at 30% (Alegria et al., 2007). Similarly, the prevalence of depression among United States Hispanics has been found to be 21% for men and 33% for women (Wassertheil- Smoller et al., 2014). While the phenomenon of females being more likely to be depressed than males is consistent across ethnic groups, it is more prominent in Hispanic subgroups (Torres Stone, Rivera, & Berdahl, 2004).

Despite the rates of psychiatric problems among Hispanics being similar to their non-Hispanic White counterparts (Hernandez, Plant, Sachs-Ericsson, & Joiner, 2005), research has consistently demonstrated disparities in access to and quality of mental health treatment for Hispanics in the United States compared to non-Hispanic Whites. In a review of epidemiological studies, Cabassa, Zayas, and Hansen (2006) found that compared to non-Hispanic Whites, Hispanics underutilize mental health services, report greater delays in receiving mental health care, are less likely to be satisfied with the mental health care they receive, and are less likely to use specialty mental health care services. In examining a national sample of Hispanic women, specifically, Ai, Appel, Huang, and Lee (2012) found that only 3.3% sought mental health services from specialists, while 5.9% reported seeking services from a general practitioner. While a number of structural, economic, and cultural factors contribute to the underutilization of mental health services by Hispanics (Sanchez, Chapa, Ybarra, & Martinez, 2012), there may be gender-based cultural characteristics and experiences that contribute to the mental health help-seeking behaviors of Hispanic women specifically (Ai et al., 2012; Caplan & Whittemore, 2013).

CONTACT Brittany H. Eghaneyan [email protected] School of Social Work, University of Texas at Arlington, 211 South Cooper Street, Box 19129, Arlington, TX 76019, USA © 2019 Taylor & Francis Group, LLC

SOCIAL WORK IN PUBLIC HEALTH 2019, VOL. 34, NO. 6, 505–518 https://doi.org/10.1080/19371918.2019.1629559

Understanding the utilization of mental health services by Hispanics in the United States requires the examination of several complex factors. Numerous studies have been conducted to examine facilitators and barriers to mental health service use among the Hispanic population. Research studies using nationally representative Hispanic samples have found lack of English language proficiency, being uninsured, lacking citizenship status, and lower education levels are all associated with lower rates of mental health service use (Berdahl & Torres Stone, 2009; Cho, Kim, & Velez- Ortiz, 2014; Lee & Matejkowski, 2012). Cabassa et al. (2006) also reported that lower levels of acculturation are negatively related to mental health service use; however, the use of acculturation in health research has been criticized due to its inconsistencies in measurement and inability to capture objective representations of cultural differences (Hunt, Schneider, & Comer, 2004).

Purpose

While researchers have identified a need for further examination on how gender influences the attitudes and use of mental health services among the Hispanic population (Cabassa, Lester, & Zayas, 2007; Cabassa et al., 2006), very little research has been conducted to fill this gap. While some studies such as Hochhausen, Le, and Perry (2011) attempt to identify factors related to mental health service utilization among Hispanic women, their quantitative nature, like many of the studies mentioned previously, limit the ability to identify all variables that may influence the mental health help-seeking behaviors of Hispanic women. To further explore the mental health treatment disparity experienced by Hispanic women in the United States, a more in-depth understanding of the factors related to mental health service use for this population is needed. Qualitative research that gives voice to the experiences of these Hispanic women can uniquely provide researchers and practitioners with the information necessary to better serve this population. Thus, the purpose of this study is to examine the experiences and perceptions of mental health help-seeking of Hispanic women in the United States using a qualitative interpretive meta-synthesis.

Method

Qualitative interpretive meta-synthesis (QIMS)

A qualitative interpretive meta-synthesis (QIMS) was chosen as the method for this study because of its ability to use multiple qualitative studies to form a more in-depth and holistic under- standing of a phenomenon while maintaining the integrity of the original studies (Aguirre & Bolton, 2014). QIMS is designed to “create a synergy of qualitative findings” by transforming each individual study “from an individual pocket of knowledge of a phenomenon into part of a web of knowledge” (Aguirre & Bolton, 2014, p. 283). The steps of QIMS include credibility reporting of the authors, sampling the literature, theme extraction, and translation (Aguirre & Bolton, 2014).

Instrumentation

Per the QIMS methodology described by Aguirre and Bolton (2014), credibility reporting in the form of a brief description of the authors’ qualifications as well as any characteristics and experiences that may lead to possible biases in analyzing the data are included.

First author I am a Licensed Masters Social Worker (LMSW) with experience working with a variety of margin- alized populations. While I identify as a mixed race woman, coming from a Mexican American and White family, I consider myself to view these experiences primarily from an outsider perspective due to my western upbringing, lack of Spanish fluency, and light complexion. However, my previous

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research experiences with Hispanic women and close relationships with Hispanic family members have provided me with a deeper understanding of the experiences of this population.

Second author I am an LMSW whose research focuses on the intersectionality of race, aging and homelessness. As a Caucasian woman without Spanish speaking ability, I approach this research from an outsider perspective.

Sampling

To generate a broad sample inclusive of all relevant studies, searches were conducted in Google Scholar, Social Work Abstracts, Academic Search Complete, CINAHL Complete, ERIC, Health Source: Nursing/Academic Edition, MEDLINE, PsycARTICLES, Psychology and Behavioral Sciences Collection, PsycINFO, ProQuest Social Sciences Premium Collection, and ProQuest Dissertations & Theses Databases. Search terms included various combinations of the topical terms Hispanic, Latina, Mexican, Puerto Rican, Cuban, women, mental health, mental illness, mental disorder, psychiatric illness, treatment, intervention, therapy, help seeking, treatment engagement, service utilization, and the methodological terms qualitative, mixed methods, descriptive, thematic, exploratory, ethnography, phenomenology, focus group and interview. Potentially relevant studies were identified via title review and were then further evaluated by reviewing the abstracts. Studies remaining after abstract reviews were obtained to evaluate for inclusion.

Inclusion criteria for this analysis were: studies published in peer-reviewed journals or dissertations that were published in English; published prior to February 2017; conducted in the United States, and; contained a sample inclusive of women identified as Hispanic or Latina, or as one of the top three largest Hispanic subgroups as identified by the U.S. Census Bureau (2011) (Mexican, Puerto Rican, and Cuban). Studies also had to be conducted using qualitative methods or mixed methods that reported qualitative findings. The topic-related criteria for the studies were the experiences and perceptions of mental health help-seeking of Hispanic women in the United States.

Initial searches yielded a total of 121 potentially relevant studies. After reviewing titles of these potential studies, including duplicates, 97 studies were eliminated. Abstract reviews conducted on the remaining 24 studies further eliminated 18 studies due to not meeting inclusion criteria, primarily because they did not address help-seeking experiences or perceptions for mental health specifically or because they were Masters theses. Of the six studies remaining, one was eliminated due to the fatal flaw that it did not include themes or quotes, which are required for the analysis process. This left a total of five studies published in peer-reviewed journals for the meta-synthesis that included experiences and perceptions of 76 adult Hispanic women and men (immigrant and US born) from various parts of the United States. Male participants that were present in two of the studies were excluded from the analysis, leaving a total of 60 Hispanic women participants. A more detailed synopsis of each study, including relevant demographics of the female participants, is provided in Table 1.

Theme extraction

Once the studies were selected, the first step in the analysis was the identification of the original themes from each study. Original themes and subthemes were extracted from each publication using the author’s wording to allow for the integrity of each individual study to be maintained. The original themes for each study and are displayed in Table 2. For one of the research studies, one major theme (and its subsequent subthemes) were excluded from the analysis because it did not relate to the help-seeking experiences of Hispanic women, but rather help-receiving. These themes are identified in Table 2.

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Translation: the path to synergistic understanding

The next step in the analysis process was the synthesis of the original themes to provide a synergistic understanding of the phenomenon using new, overarching themes. The first step of this process involved the immersion of the first author in the data and initial analysis of participant quotes (excluding any quotes from male participants and quotes representing the inapplicable subthemes identified in Table 2) within each original study using an open-coding process in Atlas.ti (7). The use of participant quotes from the original research studies is another way to maintain the studies’ integrity (Aguirre & Bolton, 2014). Next, the first author met with the second author multiple times over the course of six weeks to discuss coding and the clustering of conceptually similar codes to reach an agreed-upon translation of the initial codes into new, overarching themes. During this process, the first author also participated in two peer debriefing meetings with a colleague who is an expert in qualitative research analysis and assisted with the verification of the new themes.

Triangulation

The method of triangulation in QIMS provides verification that the translation process has produced a synergistic understanding of the phenomenon rather than a “disordered and biased misunder- standing” (Aguirre & Bolton, 2014, p. 289). The current study specifically used the triangulation of sources and analysts as described by Patton (1999). Triangulation of sources was achieved by using multiple studies that produced experiences and perceptions of mental health help-seeking collected from a total of 60 participants across the United States. Multiple meetings between the authors and expert colleague to reach an agreement of the translation of themes met the criteria for triangulation of analysts.

Table 1. Demographics of Included Studies

Author (Publication Year)

Data Collection Method N Age Ethnic Identity

Recruitment Site(s)

Recruitment Location

Callister et al. (2011) Semi- structured interviews

20 17-39, X̅ = 24

Immigrant Hispanic; 19 from Mexico, 1 from Argentina

Community health center Western state, USA

Caplan & Whittemore (2013)

In-depth, semi- structured interviews

12 X̅ = 43 Latinas; 9 Puerto Rican/American/ Latina, 1 Mexican, 1 Colombian/American, 1 Dominican

Subsidized housing community Rural area of the northeast, USA

Ishikawa et al. (2010) In-depth, flexibly guided interviews

8 Not reported

Latino Social service agencies, Latino student organization, pool of participants who had previously participated in a research project

New England metropolitan area, USA

Moreno & Cardemil (2013)

Semi- structured interviews

8 X̅ = 39.5 Latino; diverse in terms of national origin

Stores, churches, barbershops Northeastern state, USA

Pieters & Heilemann (2010)

Structured clinical interviews and motivational interviewing

12 20-48, X̅ = 29

Second-generation Latinas of Central American and Mexican descent

Health care, child development, and family service sites

Large metropolitan area of California, USA

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Table 2. Themes and Subthemes Extracted from Original Studies

Author and Publication Year Extracted Themes and Subthemes

Callister et al. (2011) Personal barriers Beliefs about emotional health, the perceived stigma of mental health, and hesitancy to seek treatment for symptoms of PPD Cultural beliefs about motherhood and the role of women Respecto

Social Barriers Lack of support Familism

Health care delivery system barriers Caplan & Whittemore (2013) Exposure to GBV and childhood adversity

Fear of disclosure Cultural values Marianismo/Familismo Religious beliefs Need to be strong

Treatment issues Negative experiences with therapy Fears about medication Denial of illness severity

Ishikawa et al. (2010) Integrating personal, family, and cultural perspectives to shape ideas of suffering and healing Personal perspectives Family perspectives

Determining what kind of help to utilize Referral source and style Identification of needs Prior experiences

*Gauging treatment satisfaction *Client-therapist match *Client-therapist relational style

Moreno & Cardemil (2013) Coping with adversity Religious coping Spiritual coping

Reasons for seeking religiously oriented mental health services Trust/comfort Similar beliefs Preexisting relationships Accessibility

Reasons for seeking formal mental health services Feeling understood Significant mental health problems Problems attributed to biological origins

Pieters & Heilemann (2010) Matters of self as a complication Time as a complication Positive motivators Urgency Inspiration to be a better parent Hope and desire for something better Personal resolve Pathfinders Conditions paving the way

Painful motivators Aware of the limits of coping alone Features of depression Visions of who I don't want to be Relationships with partners Previous ways of coping no longer work Past therapeutic encounters

Note. Subthemes are italicized. Themes marked with * were excluded from analysis.

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Results

When discussing their mental health help-seeking experiences, participants in the studies identified both formal and informal sources of help. Participants in three of the five studies discussed using friends and family as sources of help. For example, one Mexican mother emphasized the importance of close relationships with other women:

Even if they were not my direct family, they [said they] loved me and were going to help me with whatever I needed, that I should not feel alone. I needed that. They gave me a lot of support and love, and helped me with the children. They never left me alone. This helped me a lot. (Callister, Beckstrand, & Corbett, 2011, p. 445)

Women in two of five studies described their faith/religion and religious leaders as important sources of help for mental health problems, with some attributing their recovery from a mental health problem to their faith in God and belief in God’s purpose for their life. One participant from Puerto Rico stressed the effectiveness of faith and prayer by stating “ … God can help you if you really believe … ” (Caplan & Whittemore, 2013, p. 417). Women in all of the studies discussed the use of professionals and the formal health care system as a source of help for mental health problems; however, views on the roles and effectiveness of formal sources of help varied. Further discussion of experiences with professionals is presented later in the results.

Theme: determinants of mental health help-seeking

The analysis of the five studies generated several sub-themes that can be characterized as fitting into one over-arching theme of determinants of mental health help-seeking. Organization of the determinants was guided by the Andersen and Newman (1973) framework for viewing health services utilization. This theoretical framework considers societal and individual determinants in health services utilization and is built upon the notion that individual determinants are affected by societal determinants, both directly and indirectly through the health services system. Thus, the three determinants of health services utilization (societal determinants, health services system, and individual determinants) are presented as subthemes with supporting participant quotes.

Subtheme 1: societal determinants Andersen and Newman’s (1973) definition of societal determinants includes societal norms that are reflected through legislation and a “ … growing consensus of beliefs and homogeneity of values which pervade the society … ” (p. 103). While Andersen and Newman (1973) do not specifically address cultural factors in their framework, beliefs and values shared by a community that are shaped by their culture meet the criteria of societal determinants. For this analysis, women in all five studies revealed cultural factors that influenced their help-seeking experiences and perceptions.

One way in which the women spoke of culture influencing help-seeking was the expectations held for women, specifically in their fulfillment of their roles as mothers and caretakers for the family. In describing the difficulty in seeking help due to cultural expectations, one mother said “Hispanic women are very strong. It is difficult to say that we are sick. The family relies on the Hispanic mother and not the man. It is hard to accept that we need help” (Callister et al., 2011, p. 445). Other women spoke of the pressure to fulfill many roles impacting their ability to make time to care for themselves. For example, another mother stated “I have to be mother, sister, mother, spouse, so, I’m there for everyone else but I’m not there for myself” (Ishikawa, Cardemil, & Falmagne, 2010, p. 1564). Echoing similar sentiments in regards to putting other’s needs before her own, another woman reflected: “I don’t know if I’ve ever tried to pay attention to myself. I could have been depressed, I just didn’t acknowledge it, or bother seeing it in the symptoms because I was too busy dealing with other things” (Pieters & Heilemann, 2010, p. 282).

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Cultural ideas about the respect and privacy of family were also discussed as factors that affected help-seeking experiences and perceptions. For example, one woman described the lack of support from her family in seeking outside help due to the importance of family privacy: “My brother and my mother, they’re like that, it’s all in the family, it doesn’t get out, family’s first and so you go to the family. You don’t go to strangers. You don’t go to other people” (Ishikawa et al., 2010, p. 1563). For some women, whose mental health issues were related to violence and childhood adversity, the value of respect for family was particularly relevant to help-seeking. Disclosing negative personal family information to a therapist could be viewed as disrespecting family members. In explaining the importance of family respect when comparing her culture to that of White Americans, one women said:

… I’ve seen when I moved here that Americans are more cold … it’s like Puerto Ricans you cannot talk about a brother because nobody is going to allow you to talk about a family member in front of them … that is so disrespectful and that is something that Puerto Ricans do not allow. I see that, here, people can actually talk about their brothers, people can have a relationship with people that don’t get along with their mothers … If somebody did something to my brother, that person to us is dead, you are not going to say: “That’s my brother’s problem” … And here it is different, I see that all the time and my sister and me are like: “Oh my God, that’s is not the way we are.” At least where I come from. Puerto Ricans are not like that … We have to stand behind each other. (Caplan & Whittemore, 2013, p. 416)

Religious values were also important factors discussed by women in the studies. Some women described the importance of their religion in regards to their outlook on life in general. For example, one woman stated:

I’m a Christian; a born again Christian … it’s always knowing the purpose for my life that God has always had for me, and that’s what always kept me going: knowing what God has for me, knowing where He is taking me. (Caplan & Whittemore, 2013, p. 417)

Others discussed the specific ways in which religion influenced mental health help-seeking including believing the causes of mental illness were evil forces and, thus, the solutions to mental illness were prayer and a greater reliance on God. Some women described a preference for mental health providers who understood their religious beliefs whether it was professionals who identified with the same religious affiliation, or religious leaders themselves. In describing why she would prefer a religious leader as a source of help, one woman said:

That is the person [religious leader] I think is most likely [to give better advice], I mean, other people can also give me good advice [referring to professional mental health services], but I feel more comfortable talking to him because he is trustworthy. (Moreno & Cardemil, 2013, p. 59)

On the other hand, some women did not see themselves seeking help from religious leaders because of the pressure they might receive to rely on God and their faith. One woman explained:

He would have just said: “Read the bible, tell your problems to God.” That’s what he would have said: “Tell God your problems and he would help you, but you have to believe and have faith.” (Caplan & Whittemore, 2013, p. 417)

Subtheme 2: health services system The resources and organization of the health services system “shape the provision of health care services to the individual” (Andersen & Newman, 1973, p. 100), thus affecting the utilization of such services. Women in three of the studies specifically discussed aspects of the health care system that made help-seeking in formal settings difficult including the lack of culturally competent care and immediate intervention described by one woman:

They send you to another person who is not aware of how to take care of the Hispanic culture. Then they say that this woman is getting crazy over nothing, and then we do not receive the care that we really need. The appointments are set many months after. They do not help when it is needed, which may lead to more serious problems. (Callister et al., 2011, p. 446)

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Other system-level issues such as therapist turnover and difficulty in making appointments were also discussed by the women. In discussing her frustrations with therapy sessions, one woman stated, “but I don’t think its working or working fast enough. It’s so hard to get appointments and then she cancelled one time and it’s every two weeks” (Pieters & Heilemann, 2010, p. 285).

Women in three of the five studies also discussed previous experiences with formal health system services as factors influencing their help-seeking experiences and perceptions. Some women dis- cussed negative experiences with formal services and therapists, including a lack of understanding from her therapist described by one woman:

The one that I had before didn’t really understand me. When I wanted to tell her things, for example, that when I go to sleep I feel that my mind was not resting, and she thought that I needed sleeping pills, but I didn’t want that, I wanted her to tell me what could I do better. (Caplan & Whittemore, 2013, p. 417)

On the other hand, women in the studies also discussed positive experiences with therapy as motivators to continue to seek professional help. Some women described feelings of acceptance and understanding as well as the assistance therapists provided in helping the women feel less alone. In describing why she felt positively toward formal mental health services, one woman stated “I’ve gone into some kind of counseling since I was 15, off and on, because I was a runaway, and I had a real dysfunctional home, and so I’ve known – I always knew that it was helpful” (Ishikawa et al., 2010, p. 1564).

Subtheme 3: individual determinants According to Andersen and Newman (1973), there are three components to individual determinants of health care utilization: predisposing, enabling, and illness level. The predisposing component of individual determinants includes attitudes and beliefs held by individuals that may make some individuals more likely to seek and use services than others. Some women discussed beliefs about strength and how those beliefs encouraged them to seek treatment and care for themselves. In describing her motivations to seek formal help, one woman reflected, “Because it’s essential, in order for you to do anything else in life, in order to fulfill anybody else’s needs, you have to be at ease with yourself, you have to feel good with yourself” (Pieters & Heilemann, 2010, p. 281).

Another important belief mentioned by women in three of the five the studies had to do with the importance of doing the right thing for their family. In describing the importance of being able to take care of her children as a motivator to seek mental health treatment, one mother stated:

My little ones, they need me, and they need some things done, but I’m not getting things done. I don’t even know where to start anymore. I need to be able to get my things done for me and my kids. That’s a priority, so I can be okay and my kids can be okay. (Pieters & Heilemann, 2010, p. 284)

Other women spoke of not wanting to be a burden on family members anymore and the effects of their mental illness on others. For example, one Ecuadorian mother discussed alleviating her own mother from the burden of her problems: “Sometimes I feel, mothers suffer. By telling her that I have problems, that I feel bad – I know that I would make my mom suffer, so no, I don’t want to make her suffer” (Ishikawa et al., 2010, p. 1564).

Individual attitudes and beliefs about the causes and features of mental illness also affected the women’s experiences and perceptions of help-seeking. Some women viewed depression as different from other diseases, while others believed the causes of depression did not warrant treatment. For example, one Puerto Rican woman attributed her depression to situational factors:

A lot of people have real problems, so what I have to deal with is not like “Oh my God,” so maybe the people that have really big problems then it [treatment] could be helpful for them, but basically my problem is that I don’t have a job. (Caplan & Whittemore, 2013, p. 418)

Beliefs about the use of professionals for mental health also influenced the women’s help-seeking experiences and perceptions of formal health services. Women in two of the studies discussed a distrust of professionals and formal treatment settings and a fear of reliance on medication.

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Others viewed professional help as a last resort if they could not get better on their own or only necessary if their symptoms were very extreme, as explained by one Puerto Rican woman:

Maybe if I have been depressed for a very long time and felt that I couldn’t get out of it on my own. So if it meant long and stuck, or if I had some mental health symptoms that I have never had. If I ever heard voices before and stuff like that, I guess in some extreme circumstance that I would feel that way, then yeah. That is what they [mental health professions] are there for. (Moreno & Cardemil, 2013, p. 61)

Even for some women who did seek professional help, feelings of shame around past experiences, such as sexual abuse, prevented them from being honest with their mental health providers. One woman explained:

Very few people know about it [sexual abuse] – my partner, my psychiatrist, and now you. [Until recently] I never dared to tell my therapists, because I was afraid, because I was embarrassed, and because I was afraid that they were not going to understand me. (Caplan & Whittemore, 2013, p. 416)

Other women also discussed feeling guilty and ashamed for struggling with their mental health and expressed concern around what others may think of them. Another woman said, “A woman might feel locked into her own depression [and] not look for help. She might feel guilty. She wonders what she is going to do. People might think that she is crazy.” (Callister et al., 2011, p. 444–445).

The enabling component of individual determinants refers to “a condition which permits a family to act on a value or satisfy a need regarding health service use” (Andersen & Newman, 1973, p. 109). Women in two of the five studies discussed financial barriers and a lack of time as determinants in their help-seeking experiences. However, a more prevalent enabling component discussed by the women was that of social support (or lack thereof). One woman described the positive support she received from family, “My children want me to do something for myself ‘cause they know that I can do it. You know, they give me the strength to do it” (Ishikawa et al., 2010, p. 1562). Several women described a lack of support from family in receiving mental health treatment and fear of judgment if their families were to find out they had a mental illness. For example, one woman said “I wanted to get counseling but my husband wouldn’t let me because he believed that there was no way to help. He said nobody could help me.” (Pieters & Heilemann, 2010, p. 285). A lack of social support could also stem from immigration status and the resulting isolation, as described by one Mexican mother:

It is hard because there is only us here, my husband and I. It is hard if you don’t have family with you and not having someone to help you out. I didn’t have anyone to support me. What am I supposed to do? I had to press forward. (Callister et al., 2011, p. 445)

The final component of individual determinants of health care use is illness level. Andersen and Newman (1973) state that individual’s perception of their illness, including symptoms and general state, are the most immediate cause of health service use. Among the women in the studies, many who were seeking formal mental health treatment spoke of debilitating symptoms and disruptions in normal functioning. One woman reflected, “I wanna feel better. That’s why I am here, too. I get so down. And it takes a lot. I have to be like really, really strong to get up and do things. It’s an awful feeling.” (Pieters & Heilemann, 2010, p. 284). In recognizing her postpartum depression symptoms, another woman said “I felt something different, something sad. Whenever she started to cry, I felt desperate, with a desire to run away.” (Callister et al., 2011, p. 444).

Discussion

This QIMS allowed for an in-depth examination of the mental health help-seeking experiences and perceptions of Hispanic women by synthesizing results of five different studies representing parti- cipants across the United States. Results of the study revealed that Hispanic women identify the importance of both informal and formal sources of help for mental health issues. While mental health help-seeking is primarily examined in the context of formal services, the importance of informal sources of help among this population should not be negated. The recognition of

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religion/spirituality as a source of help for mental health problems among women in this study is consistent with other research describing the significance of faith and religious practices in Hispanics’ coping with mental health issues (Caplan et al., 2011; Givens, Houston, Van Voorhees, Ford, & Cooper, 2007) and highlights the need for the development of collaborative relationships with faith-based communities to create culturally targeted interventions.

Cultural values prevalent among the women that were important factors in help-seeking included the role of women, family respect, and religious beliefs. However, these values are not accounted for in most quantitative research studies examining help-seeking and healthcare utilization behaviors in Hispanic women. Instead, there is often an overemphasis on acculturation, which is a variable inconsistently measured and usually meant to quantify how assimilated individuals are to the mainstream culture rather than an examination of “the larger social structure and the dynamic social processes in which behavior and beliefs are generated” (Hunt et al., 2004, p. 981). Rather than examining the acculturation of Hispanics, understanding the specific cultural values possessed by individuals can assist in the understanding of their views toward mental illness and treatment options, leading to the development and implementation of effective interventions (Corrigan, Druss, & Perlick, 2014).

Women in the studies also discussed the role of health services systems in shaping their mental health help-seeking experiences, including organizational structure, available resources, and previous experiences within the health care system. These results suggest health care system-level interven- tions that can address the negative experiences discussed by the women that may be contributing to the underutilization of these services such as inadequate referral processes, long wait times for appointments, and poor patient-provider relationships. Research on integrated health care models in primary care settings have shown promising results as effective models of care in reducing mental illness symptoms among Hispanics and eliminating health disparities in terms of treatment atten- dance rates, improvement of symptoms, and therapeutic alliance (Bridges et al., 2014; Camacho et al., 2015; Sanchez & Watt, 2012). Preliminary findings using integrated health care models with Hispanic women, specifically, also demonstrate the effectiveness of the intervention in reducing depressive symptoms; however, more research is needed on the specific mechanisms in which the intervention contributes to improved mental health outcomes (Eghaneyan, Sanchez, & Killian, 2017).

The individual determinants of help-seeking experiences by Hispanic women in this study emphasized the role of individual beliefs and perceptions of mental health issues and help-seeking and the importance of enabling factors such as time, money, and social support. The women described feelings of shame and guilt associated with depression as well as other beliefs about the causal factors and features of the disease itself. These findings echo those of other studies in which a lack of mental health knowledge impacted Hispanic immigrants’ access to mental health care services (Ruiz, Aguirre, & Mitschke, 2013). Some of the women in the studies also discussed concerns with seeking professional help and fears of medication, while others were motivated to seek help due to severity of their symptoms and perceived burden on others. While previous research has emphasized the role of stigma in mental health help-seeking behaviors of Hispanics (Clement et al., 2015; Lange et al., 2007), the current study underscores the need to examine this stigma in the context of other enabling factors such as social support and the health services systems barriers experienced by this population.

Implications for social work

Results of this study affirm that mental health help-seeking behaviors and perceptions of Hispanic women are influenced by a complex set of factors at both the individual and societal level. Therefore, interventions aiming to alleviate the suffering experienced by these women must be implemented at the individual, community, and healthcare system level. Given social workers’ person-in- environment approach to addressing social injustices, practitioners and administrators are in a unique position to promote and implement interventions at all levels. Ashcroft and Van Katwyk

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(2016) point out that Western health care is dominated by a biomedical paradigm which tends to negate the impact of political, social, economic, and environmental influences on people’s health. However, the authors maintain that social workers have gained acceptance in the medical commu- nity and should strive to challenge “the dominant discourse to provide greater understanding of how social relationships, politics, and culture” influence health (Ashcroft & Van Katwyk, 2016).

By the same token, social workers are called to recognize the function of culture in human behavior and society and “demonstrate competence in the provision of services that are sensitive to clients’ cultures” (National Association of Social Workers, 2008, section 1.05). The National Institutes of Health also emphasizes the importance of cultural respect in the delivery of health care services to eliminate health disparities and improve access to high-quality health care (National Institutes of Health). However, models of cultural competence in mental health care systems are criticized for several shortcomings including treating culture as a variable, conflating culture with race and ethnicity, ignoring diversity within groups, and inadvertently placing blame on patients’ culture (Carpenter-Song, Schwallier, & Longhofer, 2007). Therefore, social workers should advocate for culturally competent mental health care services that recognize and respect the identity of individuals and how those identities are shaped by interactions within multiple networks and communities rather than oversimplifying culture as a variable that is a property of only those individuals within racial and ethnic minority groups (Carpenter-Song et al., 2007; Kirmayer, 2012). Caplan et al. (2013) suggest that in order to provide culturally congruent care when working with patients directly in the provision of mental health services, practitioners should assess patients’ understanding of symptoms, traumas, spirituality/religion, acculturative stress, and support system.

Many of the nation’s 600,000 licensed social workers work in public health or medical settings, utilizing interdisciplinary collaborations to focus on client physical and mental health outcomes (Miller et al., 2017). Given their prevalence in the mental and physical health care arenas, social workers are uniquely suited to use the results of this QIMS and other qualitative research regarding help seeking behaviors of Hispanic women. In the short term, social workers can advocate for clinics to provide services that will allow women to seek formal mental healthcare. This could include childcare, transportation, and other measures that allow women to feasibly seek care while also tending to other responsibilities like motherhood. In the long term, social workers should collaborate on public education campaign strategies to empower Hispanic populations to destigmatize mental health help seeking, both for themselves and for their families. Meanwhile, social work educators should strive to increase the number of culturally competent social workers coming out of under- graduate and graduate schools of social work. Courses should focus on patient-centered principles of culturally competent care as well as culturally adapted education tools to increase retention and engagement in mental health treatment.

Finally, social work researchers should continue to examine the issue of mental health care disparities experienced by Hispanic women. Research using social work’s social justice perspective can bring to light the political and structural forces contributing to mental health help-seeking experiences that are often ignored in other fields of health research. Additionally, continued emphasis on qualitative or mixed-methods experiential research giving voice to Hispanic women can provide a greater understanding of the barriers and facilitators to receiving mental health care, contributing to the elimination of the mental health disparities experienced by these women.

Limitations

This study’s findings are limited by its small sample size due to the lack of published research on the mental health help-seeking experiences of Hispanic women. This gap in the literature also created the necessity to combine studies containing participants of various ethnic backgrounds including Mexican, Argentinian, Puerto Rican, Colombian, Dominican and Central American. However, research has demonstrated that Hispanic subgroups differ in their prevalence of mental illnesses as well as in their rates of mental healthcare use (Ai et al., 2012; Alegria et al., 2007; Berdahl & Torres

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Stone, 2009). Likewise, this study combined the experiences and perceptions of both US-born and foreign-born Hispanic women despite research showing that they utilize mental healthcare services at different rates (Alegria et al., 2007; Cabassa et al., 2006). This demonstrates the need for continued research, specifically that of the qualitative nature, to better understand the differences that may exist in mental health help-seeking experiences for women in different Hispanic subgroups. An additional limitation was that three of the five studies analyzed for the current study specifically examined help- seeking in formal healthcare settings; therefore, the informal help-seeking experiences of Hispanic women may be underrepresented.

Conclusion

Despite similar rates of psychiatric disorders compared to their White counterparts (Hernandez et al., 2005), Hispanic women are less likely to use professional mental health care services (Ai et al., 2012). Examining the mental health help-seeking experiences of Hispanic women provides a deeper insight that is lacking in many quantitative studies as to why this population underutilizes these services. This QIMS provided a holistic understanding of the many complex factors that affect mental health help- seeking at the societal, health services system, and individual levels. To eliminate disparities experienced by Hispanic women in mental health care services, more research is needed on the specific processes in which these experiences shape treatment engagement and retention for this population.

Disclosure statement

No potential conflict of interest was reported by the authors.

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